Hormonal agents
Two estrogen-containing oral contraceptives are approved by the FDA for acne treatment: Ortho Tri-Cyclen, which contains norgestimate with ethinyl estradiol, and Estrostep, a norethindrone acetate/ethinyl estradiol preparation. Similar products appear to be comparably effective, but there has been little research on transdermal patches and vaginal rings.
Among the available oral anti-androgens, spironolactone and cyproterone acetate may be useful. Flutamide carries the risk of hepatic failure, and finasteride has not been reported to be effective. Evidence for the efficacy of oral corticosteroids is limited. However, an expert consensus suggests that short courses provide at least temporary benefit for severe inflammatory acne, and low dosages may be useful for patients with adrenal hyperandrogenism.
Isotretinoin
Oral isotretinoin is a powerful drug. It is approved for one indication only, i.e., severe treatment-resistant nodular acne, but the Guidelines work group unanimously endorsed its utility for less severe acne that resists other treatments or threatens to inflict significant physical or psychological scarring.
The potential for adverse effects with use of this agent is substantial, however. Because of its high teratogenicity, all patients using isotretinoin and clinicians prescribing it must participate in a risk-management program, iPLEDGE (www.ipledgeprogram.com). The drug also carries the risk of mucocutaneous, musculoskeletal, ophthalmic, and central nervous system consequences associated with hypervitaminosis A.
Mood disorders and suicidality have been seen in patients given isotretinoin, although a causal connection is unclear (particularly given the high prevalence of such phenomena in the adolescent and young adult population most often treated with the drug). “It is important to query the patient about emotional lability and to look for signs of depression,” says Dr. Van Voorhees.
In light of these important issues, “this drug should be prescribed only by those physicians knowledgeable in its appropriate administration and monitoring,” the Guidelines authors conclude.
Alternative/complementary therapy
A number of diverse herbal and other alternative approaches have been and continue to be used for acne. Many seem to be well tolerated, but none has substantial data to support safety or efficacy.
Tea tree oil was shown to be effective in a single clinical trial, although it appears to work more slowly than other topical preparations. The benefits of psychological interventions, notably biofeedback and cognitive imagery, are supported by “weak” evidence, the authors say.
At the time the Guidelines were written, there was no substantial evidence that diet or dietary modifications influenced acne. More recently, however, a controlled study found evidence that a diet low in high-glycemic foods (e.g., simple sugars) could improve symptoms.
Guidelines of Care for Acne Vulgaris Management was published in Journal of the American Academy of Dermatology (2007; 56:651-663).
Mr. Sherman is a medical writer in New York City.